A Scar Nobly Got

The story of the US government’s efforts to stamp out smallpox in the early 20th century offers insights into the science and practice of mass vaccination.

By Michael Willrich | July 1, 2011

PENGUIN PRESS, MARCH 2011

Our skins record the histories of life’s close scrapes. One of the most common marks that humans carry is, we hope, bound for extinction: the nickel-sized cicatrix left by a successful smallpox vaccination. The deadliest disease in history, smallpox was eradicated worldwide more than thirty years ago. With each passing year, fewer of the world’s inhabitants bear the mark of smallpox vaccination on their arms. Fewer still can remember what those scars once meant. Our fading vaccination scars are not simply a tattooed testament to one of the greatest scientific and medical triumphs of all time. These scars are also a reminder of the shocking level of coercion and harsh treatment once used in vaccination campaigns—and the widespread popular resistance sparked by those measures.

Consider the United States at the turn of the last century, the setting for my new book, Pox: An American History. As smallpox spread across much of the country, infecting and killing thousands, a vaccination scar on the upper arm assumed a new sociopolitical significance. Of course, the mark—a solitary replica of the pitted scars that the Variola virus left upon the faces and bodies of the unvaccinated—had always signified medically administered immunity from smallpox. By 1900 the mark of vaccination, a medical practice already more than a century old, should have occasioned little notice. But as the United States stepped onto the global stage as an imperial power, the most productive industrial economy in the world, and a principal destination for the world’s immigrants, the scar became a badge of “civilization” and citizenship.

Immigrants could not enter the country without one. On US soil, the scar served as a kind of domestic passport, required for admission to many schoolhouses, workplaces, and public spaces. During a smallpox outbreak, anyone who lacked a vaccination scar risked arrest, shotgun quarantine, and, if the person refused to bare an arm for the vaccinator’s lancet, forcible immunization. Seasoned health officers knew better than to trust paper vaccination certificates; they demanded to see the scar. As one writer noted in American Medicine, “This certain, well-defined sign cannot be forged.”

That writer was wrong. As health officials and police aggressively enforced vaccination, resourceful vaccine refusers discovered ways to fake the scars. Some tried plaster counterfeits. Others followed home remedies promoted in unorthodox medical journals. “Get a little strong nitric acid,” advised Medical Talk for the Home. “Take a match or a toothpick, dip it into the acid, so that a drop of the acid clings to the end of the match. Carefully transfer the drop to the spot on the arm where you wish the sore to appear. Let the drop stand a few minutes on the flesh.” After a few minutes, the burning skin turned red—time to blot up the remaining acid. In a week, the spot turned dark. “This sore,” the journal promised, “will gradually heal by producing a scar so nearly resembling vaccination that the average physician cannot tell the difference.” Alarmed health officials condemned such forgeries as a “vile crime.”

As wrongheaded as such resistance may seem today, the public’s wariness of immunizations was often justified: at the time, health officials ordered vaccinations without taking measures to ensure their safety and efficacy. Fortunately, the turn-of-the-century vaccine wars left their marks not only upon the nation’s arms but also on its law books. In order to strengthen public confidence in vaccines, Congress enacted the Biologics Control Act in 1902, establishing a new federal system for licensing and regulating vaccines. American courts issued rulings that placed public health authority on firmer legal ground while also establishing key protections for individuals’ civil liberties. Perhaps most important, popular opposition taught government officials that when it comes to public health, education can be more effective than brute force.

The stories our scars can tell.

Michael Willrich is the author of City of Courts, which won the John H. Dunning Prize awarded by the American Historical Association for the best book on any aspect of United States history. An associate professor of history at Brandeis University, Willrich has written for the New York Times, Washington Monthly, the New Republic, and other magazines. Read an excerpt from Pox: An American History.